A new study from the Ontario College of Family Physicians has found that 2.2 million of the 14 million residents of Canada’s largest and wealthiest province have no family doctor. The finding is a major indictment of the for-profit or fee-for-service model that is now being promoted as the go-to model for Ontario’s surgeries by the province’s conservative government.
“The number of unattached patients is growing across the province and region,” says Steve Gray, chief executive officer of Medical Associates of Port Perry. “The wait list at Medical Associates has never been so high and it will only grow further as our family physicians retire.”
According to the Ontario College study, over forty thousand Torontonians, five thousand Mississauga residents, and many more across the province lack access to a regular physician. Those lacking a family physician typically delay necessary follow-ups on serious health problems, resulting in these problems becoming markedly worse. This, in turn, places further pressures on other areas of the provincial health care system — especially Ontario’s overwhelmed emergency departments.
It is a problem of a snake-eating-its-own-tail variety. The lack of family physicians leads to delayed follow-ups on health issues, which worsens health problems, putting additional strain on the already overwhelmed emergency departments. The entire scenario jeopardizes the province’s health care system, providing the perfect opportunity for for-profit merchants to double down on their “solutions.”
Causes, Effects, and New Causes
Part of the cause of the drop in coverage likely comes from an overall drop in the total number of family doctors throughout the pandemic. Ontario had 12,247 active family doctors in 2019 but only 11,862 between March and September 2020. As CBC News reported, Ontario’s lockdown policies — which directed family doctors to refrain from seeing patients unless it was absolutely necessary — resulted in visits dropping by nearly 30 percent. As most family doctors and walk-in clinics are private operators, billing the province under the fee-for-service model pushed many to close up shop.
“For fee-for-service doctors, it meant a huge drop in their income all of a sudden,” Dr Tara Kiran, a family doctor and researcher at St Michael’s Hospital, told CBC News. “At the same time, they needed to pay their staff, pay their rent like every other small business.”
Making matters worse, as the Toronto Sun observed, “Ontarians are increasingly denied medical services paid for by their taxes [because] provincial governments of all stripes, have been decreasing the number of services and drugs covered by OHIP [the Ontario Health Insurance Plan] to save money.”
This was especially true of family doctors in more remote areas and with fewer than five hundred patients. “Rural areas have lower numbers of doctors to begin with, so a few of them leaving had a greater effect on those communities,” Kiran told CBC News.
But the trend precedes the pandemic. As the same CBC News article notes, in March 2020, 1.8 million Ontarians already lacked access to a family physician. More than a decade earlier, in 2008, a Health Policy study estimated that 7.8 per cent of Ontarians — roughly 0.9 million of 12.88 million — were “unattached” or lacked a family doctor.
This deficit, the Health Policy study notes, hampered the system’s ability to provide earlier treatment for potentially difficult conditions, provide preventative care (such as blood pressure checks, mammograms, and Pap smears), and manage chronic diseases. Largely, those without access are younger, poorer, and typically members of immigrant communities. Overall, this population has poorer health outcomes than middle-class Canadians.
As the Health Policy study observed:
Those without a family doctor were more likely to be male, younger or recent immigrants. Their employment status was more likely to be employed or unemployed, and they were less likely to report chronic conditions. Ontarians with a family doctor were more likely to be retired, have two or more children or be established immigrants. They were more likely to report they have confidence in the healthcare system and also more likely to have multiple chronic conditions.
Part of this may be explained by the fact that rich people have better health than poor people do, often living longer and experiencing less disability. Wealthier people often have the ability to take time off to see a family doctor, whereas the poor must rely on paid sick leave policies.
A Major Indictment of Privatized Health Care
Given that Ontario’s successive right-wing governments have historically relied on family doctors and preventative care as a tool to offset their cuts to hospitals and nurses, the family doctor deficit is clearly troubling.
Last September, Ontario’s hospitals were overwhelmed by influxes of RSV and COVID-19 patients. Instead of reversing the government’s cut to health care wages, Ontario health minister Sylvia Jones worked to deflect attention from the government’s cuts — by insisting that family doctors would step up.
“We need to make sure that primary care practitioners are seeing their patients before they have to go to an emergency department or a hospital,” Jones said. “We have a robust system when all of the players are working together. And we need all those parts to be basically operating at 100 per cent.”
Elsewhere, others in the health care administration have promoted this same fee-for-service system, where doctors run effectively private but publicly insured facilities, as the model for how privatizing other services would supposedly improve access.
The most visible moment of the crisis thus far occurred earlier this year, when the government responded to soaring backlogs and wait times by pushing to move surgical procedures — chiefly cataract surgeries, MRIs, CT scans, and hip and knee replacements — from hospitals into mostly for-profit “Independent Health Facilities” (IHFs).
“Let’s get the cataract surgeries, get the backlog there. Let’s change people’s lives, and take care of the hip and knee replacement surgeries,” Ontario premier Doug Ford said. “You add ’em all up, what I understand is that’s 50 percent of the surgeries.” The privatization scheme has been punctuated by a massive spike in hospital emergency room closures — totaling over 184 days of lost service, across the province, from March 2022 to 2023.
Despite these sorts of catastrophic developments, free-market proponents remain undeterred. Andrew Pak of the Ontario Medical Association told the Globe and Mail, “Your family doctor’s office is a for-profit business. . . . It’s a private business within a publicly administered health care system.” Indeed, the call may be coming from inside the house. As the National Post observed, “The outpatient plan is supported by the Ontario Hospital Association, the Ontario Medical Association and multiple hospital CEOs. Don’t be surprised if it’s hospitals themselves that lead the way by establishing satellite surgery centers.”
For-Profit Entities Cannot Provide Universal Care
The battle with champions of private care is one that goes back to the earliest days of Canada’s Medicare program.
In the early 1960s, Saskatchewan’s Cooperative Commonwealth Federation (CCF) government expanded its provincial health insurance plan with the Saskatchewan Medical Care Insurance Bill. Immediately afterward, lobbying, threats, and walkouts by for-profit doctors worked to stop the government from employing physicians in public clinics like the one in Swift Current.
Advocating for the initial CCF position, spokesperson Dr Hugh MacLean said in a 1937 radio address:
In our present system of practice, preventive medicine is largely neglected because the members of the [medical] profession are almost wholly engaged in the curative end of practice, so that preventable deaths are not being prevented and correctable conditions are not being corrected because the people are not in a financial condition to have their condition discovered.
Instead, the right-wing Keep Our Doctors campaign famously led the fight to prevent a salaried system and defend their private facilities and payments. Warning of the dangers of “socialized medicine,” they firmly opposed calls for “an exclusively salaried service” and pushed instead for “state-aided health insurance on a fee-for-service basis.”
Eventually, the CCF government capitulated. The result was that family doctors and hospitals in Canada are not public institutions. They are private facilities that offer publicly insured services — and they often play the part to the hilt. Both the Ontario Hospital Association (OHA) and Ontario Medical Association (OMA) have supported privatization efforts in the past. In the 1980s, the OMA’s federal counterpart, the Canadian Medical Association, was adamant, according to former health minister Monique Bégin’s account, that “all sources of private financing of health insurance should be permitted.” Since then, a good number of medical professional associations have been quick to champion privatization.
In the 1990s, then OHA CEO David MacKinnon declared that the drive to partner with the private sector was already “guiding our hospital system.” This was made easier, he noted at the time, by the fact that “many members of hospital boards and a disproportionate number of the board chairs are business people.”
The principle of universal health care dictates that those who are sickest are most in need of care. That requires accessible health care, free at the point of use. Leaving this aim to small businesses, which operate with famously tight margins, and a network of private fiefdoms may be one of the worst ways to achieve this end.
Private health care providers are beholden first and foremost to the drive for profit. Their unequal provision frequently reflects social inequalities. Such inequalities are the very thing that a universal health system — especially one that purports to provide preventative care — aims to prevent. A properly universal program is a public program. Public health care, with full ownership and provision of services, can execute its directives independently. It is free from the capricious needs and irregularities of the market. It is the only sane and efficient answer to the crisis of Ontario’s family doctor deficit.